The need to re-establish public confidence in medicine's ability to regulate itself after a series of scandals remains a continuing challenge. In January 2001, the Lord Chief Justice of England and Wales summed up what he perceived as a radical change in public attitudes, noting that medical negligence litigation “was a disaster area” and complaints to the General Medical Council (GMC) were expected to rise to around 4,500 in 2001. Reflecting what he claimed were changing public expectations, he announced the (...) end of the courts' “presumption of beneficence” on the part of doctors. He criticised the judiciary's past deference to medical opinion and claimed that society was shifting its focus from concepts of duties to individuals' enforceable rights. This “move to a rights based society”, he said “has fundamentally changed the behaviour of the courts” and by reference to a number of recent major medico-ethical cases, highlighted how the courts rather than doctors appeared increasingly as the ultimate arbiters on questions of medical ethics. Media attention crystallised around two major issues which exposed flaws in self regulation: the unauthorised retention of organs from deceased patients and the implications of the Shipman case, in which a general practitioner, Harold Shipman was found guilty of murdering 15 of his patients. In May 2000, in his interim report on paediatric practice at Bristol Royal Infirmary, Professor Ian Kennedy drew attention to the fact that organs of deceased children had been retained without their parents' knowledge or consent. It soon became evident that this had been a common practice in other hospitals, both after coroners' postmortem examinations (which do not require relatives' permission) and so-called “hospital postmortems” (which do require such authorisation). The report noted that current law was confused and a detailed code of practice was needed to clarify the circumstances in which …. (shrink)

The election of George Bush heralded a shift to the right in American politics and with it the expectation of a more conservative approach to issues such as abortion. In an interesting twist, however, the Wisconsin Supreme Court has upheld a decision that has been described as potentially “coercive of abortion”. David Oakley, a father of nine children with four different mothers was found guilty of intentionally refusing to pay child support and was sentenced to three years in prison followed (...) by five years' probation. As a condition of his probation, Oakley cannot have any more children unless he demonstrates that he has the ability to support them and that he is supporting the children he already has. Failure to comply with the conditions of the probation would result in a further eight years' imprisonment. Oakley argued that the condition violated his right to procreate, since he was unlikely ever to be able to support all of his children, but his appeal was rejected. The majority decision held that, since the conditions were “not overly broad” and were “reasonably related to the person's rehabilitation”, the conditions of probation could legitimately impinge upon constitutional rights. In dissenting from the majority decision, Ann Walsh Bradley, J stated: “[b]ecause the condition is triggered only upon the birth of a child, the risk of imprisonment creates a strong incentive for a man in Oakley's position to demand from the woman the termination of her pregnancy. It places the woman in an untenable position: have an abortion or be responsible for Oakley going to prison for eight years”.1 One commentator has pointed out that, in this case, “one precept of rightwing politics–that the state should not pay for the upkeep of offspring irresponsibly acquired–has come into conflict with another: that normal healthy people should …. (shrink)

All international statements of human rights comprise a mixture of liberty rights (such as freedom of expression, freedom from unjustified arrest or detention) and positive claims to social support. In general, the latter have received far less attention than the former although this now seems set to change. The 1948 UN Universal Declaration of Human Rights included “the right to a standard of living adequate for health and wellbeing, including food … medical care and necessary social services” (article 25). In (...) the ensuing fifty years, however, this human right rarely seemed to be centre-stage even though it was reflected in the constitution of the World Health Organization (itself a specialised agency of the UN) which famously defined health as “a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity”. One of the reasons for the apparent dismissal of the notion of a right to health in much previous ethical debate has been that while such a right is clearly a good thing, what is actually entailed, whether it is practically deliverable and from whom has long remained unclear. Now, however, concrete guidance is gradually emerging, leading to increased emphasis on this area of human rights, not just by specialised human rights lawyers and pressure groups but also by ethicists and medical organisations. The Commonwealth Medical Association, working with the American Association for the Advancement of Science, recently completed a report on the meaning and content of “the right to health”. The British Medical Association (BMA) has also recently compiled a major report on how the interface between medicine and human rights is changing, devoting much attention to the right to health, a right to a minimum standard of health care and the concept of an ethical duty to respond to need.1 …. (shrink)

Management of prisoners on hunger strike has always been a contentious ethical issue. Two arguments are advanced. One is that the authorities and prison doctors have duties to save prisoners' lives. This can entail forcible feeding. The counterargument is that prisoners retain certain rights, including that of deciding when to refuse medical treatment and artificial nutrition. In some countries, practice involves respecting prisoners' refusal of food until they lose consciousness and then forcibly feeding the then incompetent person, on the grounds (...) of “best interests”. In the UK, the arguments came to a head in the 1970s when two Irish prisoners, the Price sisters, legally challenged the Home Office's right to force-feed in any case other than where refusal of food arose from a medical or psychiatric condition. It caused a furore and the earlier prison policy of involuntary feeding was overturned. In 1981, the wishes of hunger strikers, including IRA prisoner Bobby Sands, were respected and doctors supervised death-fasts in Northern Ireland. During the 1980s and 90s, the same arguments were used in response to mass hunger strikes in Spain, Morocco and South Africa. In Spain, where 60 political prisoners fasted, some regional judges ordered forcible feeding, while others allowed prisoners to fast. The debate about conflicting moral duties became highly political and in 1990 a Spanish doctor who began involuntary nutrition of hospitalised prisoners was assassinated. Nevertheless force-feeding continued until 1991 when the strike ended. In the same year, in South Africa, sophisticated protocols evolved which applied the concept of advance directives (binding advance refusals) to force-feeding. Since 1980, hunger strikes by political prisoners have been endemic in Turkey where well documented allegations of torture are common. In 1996, for example, 12 hunger-strike deaths occurred in prison. In December 2000, two types of hunger strike began: over 2000 protesters …. (shrink)

The Netherlands has waited a long time for parliamentary endorsement of euthanasia, despite it being accepted practice for many years. Until recently, euthanasia and assisted suicide were technically illegal in the Netherlands, although court rulings during the 1970s and 80s indicated that a defence of necessity could be invoked by a doctor who ended the life of a patient. The situations in which that defence could be used were defined and became the Royal Dutch Medical Association's “rules of due care”. (...) Many of the safeguards in the rules passed into statute in April 2001 with the passing of the Termination of Life on Request and Assisted Suicide (Review Procedures) Act. The act decriminalised euthanasia and assisted suicide by doctors acting with “due care”. Doctors will not face prosecution if they terminate the life or assist in the suicide of a patient who has made a voluntary and well considered request, is facing “interminable and unendurable suffering”, understands his or her situation and prospects, and for whom there is no other reasonable solution. A second, independent, doctor must be consulted. There is no requirement for the patient to be terminally ill, and there are specific provisions that allow the euthanasia of young people between the ages of 12 and 16 if they and their parents agree. Parents of 16- and 17-year-olds must be involved in decisions about the young person's end-of-life care, but these patients are entitled to make their own decision. There is no requirement for the patient to be a Dutch resident. The Dutch justice department's website has the English language text of the act and an explanatory factsheet at www.minjust.nl:8080/a_beleid/fact/suicide.htm. In the light of the legislation, the World Medical Association (WMA) has reaffirmed its opposition to euthanasia and its strong belief that euthanasia is in conflict with …. (shrink)